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Infectious Diseases in Clinical Practice:
doi: 10.1097/IPC.0b013e3181373d27
Reflections of an ID Specialist

Passing the "TORCH"

Tolan, Robert W. Jr MD

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Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital, New Brunswick, NJ and Drexel University College of Medicine, Philadelphia, PA.

Address correspondence and reprint requests to Robert W. Tolan, Jr, MD, MOB 3110, 254 Easton Ave, New Brunswick, NJ 08901. E-mail: rtolan@saintpetersuh.com.

A newborn in the second week of life was recently admitted for jaundice, failure to thrive, hypothermia, and apnea. She was a 2-kg intrauterine growth-restricted second baby to a young mother with a 2-year-old toddler at home. At birth, she was jaundiced, small for gestational age, microcephalic, and noted to have petechiae. She failed newborn hearing screening. She was evaluated and sent home with her mother.

When she was seen for a follow-up visit, she had gained almost no weight, and her condition had deteriorated significantly. She remained jaundiced with diffuse petechiae. Her head was small, and her sutures were overriding. She had significant hepatosplenomegaly, anemia, and thrombocytopenia. Computed tomographic scanning of her brain showed massive hydrocephalus ex vacuo with a rim of periventricular calcification surrounded by a sliver of cortex. Her urine specimen obtained at birth grew cytomegalovirus.

Congenital infections uniquely bridge the worlds of internists and pediatricians practicing Infectious Diseases, as we grapple with the prevention of these potentially devastating infections and struggle with diagnosis and management in their aftermath. Interestingly, the long-time editors of the definitive textbook in the field,1 Drs Jack Remington and Jerome Klein, are an internist and a pediatrician, respectively.

Many of us grew up in the era of "TORCH" titers (an acronym that persists, unfortunately). It was proposed by Dr AJ Nahmias in the early 1970s2,3 and soon became widely used because the "TORCH" infections shared distinct attributes that made grouping and thinking about them together appropriate. In the neonate, these infections are difficult to distinguish and often not overtly apparent (except for herpes simplex virus infection). They are generally subclinical in the mother as well. Finally, making the diagnosis of one of these infections usually requires special laboratory testing of mother and baby. Numerous authors and authorities have noted that the acronym should serve as a reminder to think, in careful and systematic fashion, of the vast differential diagnosis of congenital infection rather than as a list of serological tests to perform. Too often, however, "TORCH" titers are blindly ordered, the proposed thoughtful approach overlooked in the bustle.

As our recognition of in utero infections has grown, the acronym has evolved. When I began training some 20 plus years ago, we used "STORCH" titers, as we recognized that syphilis was too important to omit and Dr Greg Storch (an internist and virologist practicing Pediatric Infectious Diseases and now division chief) was teaching us medical students about these infections. Others, I am sure, used "TORCHeS" or some similar variant.

Over the years, the landscape has changed, the textbook has expanded, and the acronym has been rearranged and distorted to encompass the entities now thought to merit inclusion. These variants of the original acronym, while moving further from the historic grouping of the "TORCH" infections, are certainly more inclusive. The most recent iteration, "ToRCHES CLAP,"4 omits lymphocytic choriomeningitis virus,5 among others, and lacks aesthetic appeal. Other recently proposed candidates, including "THE BAC PORCH,"4 "CHAST LOVER,"6 and "CHEAP TORCHES,"7 are similarly unsatisfactory.4

I have proposed8 "SHARP COLLECT" as an inclusive, elegant, and more easily recalled version of this congenital and perinatal infections acronym:

* Syphilis

* Herpes simplex virus

* AIDS (acquired immunodeficiency syndrome due to human immunodeficiency virus)

* Rubella

* Parvovirus B19

* Cytomegalovirus

* Others as yet to be determined

* Lyme disease (Borrelia burgdorferi)

* Lymphocytic choriomeningitis virus

* Enteroviruses

* Chickenpox (varicella-zoster virus)

* Toxoplasma gondii

This list encompasses almost all of the currently agreed-upon infectious agents, while leaving room for geographically limited (eg, congenital babesiosis) and future ones ("O" is a broad category). Unfortunately, toxoplasmosis lands at the end of the list, but the options beginning with "T" have limited applicability and appeal.

Making a diagnosis when confronted with a newborn such as the one described here is straightforward. Ethical and short- and long-term management issues pose the challenge with this sort of patient. Other patients, with perhaps more perplexing diagnoses, will benefit from a thoughtful, rather than rote, approach to evaluation. If this proposed acronym, "SHARP COLLECT," helps those taking care of these mothers, babies, and families to formulate a differential diagnosis and diagnostic approach, so much the better.

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REFERENCES

1. Remington JS, Klein JO, Wilson CB, et al. Infectious Diseases of the Fetus and Newborn Infant. 6th ed. Philadelphia, PA: Elsevier Saunders; 2006.

2. Nahmias, AJ, Walls KW, Stewart JA, et al. The ToRCH complex-perinatal infections associated with toxoplasma and rubella, cytomegalo- and herpes simplex viruses. Pediatr Res. 1971;5:405-406.

3. Nahmias AJ. The TORCH complex. Hosp Pract. 1974;9:65-72.

4. Klein JO, Baker CJ, Remington JS, et al. Current concepts of infections of the fetus and newborn infant. In: Remington JS, Klein JO, Wilson CB, et al. Infectious Diseases of the Fetus and Newborn Infant. 6th ed. Philadelphia, PA: Elsevier Saunders; 2006:3-25.

5. Tolan RW Jr. Lymphocytic choriomeningitis virus (LCMV). eMedicine Journal [serial online]. 2003. Available at: http://www.emedicine.com/PED/topic3051.htm. Accessed February 5, 2007.

6. Ronel DN, Klein JO, Ware KG. New acronym needed for congenital infections. Pediatr Infect Dis J. 1995;14:921.

7. Ford-Jones EL, Kellner JD. "CHEAP TORCHES": an acronym for congenital and perinatal infections. Pediatr Infect Dis J. 1995;14:638-640.

8. Tolan RW Jr. Review of Infectious Diseases of the Fetus and Newborn, 6th Edition. Clin Infect Dis. 2006;42:1062-1063.

© 2008 Lippincott Williams & Wilkins, Inc.